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3.
EMR Trends in Health Care
• The U.S. spent over $2.2 Billion in health care in 2008,
yet most of the information exchange is rudimentary
• According to the CDC’s National Center for Healthcare
Statistics 2007 survey, only 25.9% of medical practices
had some form of EMR
• U.S. is adopting EMR technology at a much slower rate
than other industrialized nations
• According to a 2007 study conducted by the Institute of
Public Health, Physicians who use electronic health
records believe “(EMR) systems improve the quality of
care and are generally satisfied with the systems”

4.
Government’s Role in Promoting EMR
Technology
• Promoting incentives for quick implementations of
EMR in medical practices
• CMS is paying incentives to physicians for reporting
quality data using EMR
• Since early 2005 the Department of Veterans Affairs
(VA) Hospitals have been adopting an EMR
• Proposed bills introduced to incorporate EMR
technology within all physician offices over the next
3 years
• HHS Secretary Mike Leavitt is promoting EMR
technology as means of change reimbursement and
slowing the rise in health care spending

5.
Proposed Reimbursement Changes
• Government’s position on reducing cost is to tie provider
reimbursement to quality data and outcomes
• Medicare (CMS) already began quality based
reimbursement with the PQRI program
• Some plans are beginning to follow the government’s
lead

6.
What We Hear as Reasons to Not
Implement and EMR
• Costs are too high
• Electronic health technology
will interfere with my office
workflow
• An EMR will slow me down,
I’ll see less patients
• I’m going to wait to see the
“technology direction” of the
hospital
• A huge undertaking and may
not practice much longer
Doctor, nurse picture

8.
8
“This will cut waste, eliminate red
tape, and reduce the need to
repeat expensive medical tests.
It just won't save billions of
dollars and thousands of jobs -- it
will save lives by reducing the
deadly but preventable medical
errors that pervade
our health care system.”
- President Obama
Eventful Times: The Need for Electronic
Health Technology is Now

9.
American Recovery and Reinvestment Act
of 2009, H.R. 1 (ARRA)
• This legislation includes over $19 billion in funding for
health information technology (HIT) infrastructure and
adoption. Additional allocations for training, research
and quality increasing the total funding for health care
initiatives to over $59 billion.
– Health Information Technology for Economic and Clinical Health
Act (HITECH) provides $19.2 billion in funding for HIT.

11.
Health Information Technology for Economic
and Clinical Health Act (HITECH)
• $17 billion in incentives require proof of "meaningful" use
– Use of a certified product as determined appropriate by the Sec.
of HHS
– The EHR technology must be connected
– Complies with submission of reports on clinical quality measures
• “Early Adopters”, those that adopt first will benefit the
most (declining incentives)
– Physicians can earn between $44,000 to $64,000 over five years
from Medicare / Medicaid if they are utilizing an EHR in 2011
• Late adopters will receive significantly less
• Providers may receive incentives under only one of the programs
• 2015: reductions in Medicare/Medicaid fees for non-EHR users
• Hospitals can earn up to $2,000,000 plus discharge
bonuses (total payout to them could be $10 million +)

12.
Medicare Incentive Payments
• Medicare incentive payments will be available to “eligible
professionals and hospitals” for the first five years 2011-
2015
– If eligible professionals and hospitals do not demonstrate
meaningful use by 2015, Medicare payments will be reduced
• First Payment Year
– $18,000 if the first payment year is 2011 or 2012
– $15,000 if the first payment year is 2013
– $12,000 if the first payment year is 2014
• Second Payment Year: $12,000
• Third Payment Year: $8,000
• Fourth Payment Year: $4,000
• Fifth Payment Year: $2,000

13.
Medicaid Incentive Payment (State/HHS)
• This section authorizes States to pay Medicaid providers
no more than 85% of the net average allowable costs for
certified EHR technology (maximum of $64,000 over 5
years). Secretary of HHS is to study costs of EHR and
determine the “net average cost.”
• Eligible Medicaid providers must first demonstrate use
by 2015 and eligibility for incentive ends after 2021
• Eligible providers include:
– Non-hospital based pediatrician with at least 20% of patient
volume receiving medical assistance (Medicaid)
– Children’s hospitals or an acute care hospital that is not a
children’s hospital that has at least 10% of the hospital’s patient
volume attributable to individuals receiving medical assistance

16.
Summary of Incentive Opportunities
• $44,000 to 64,000 available per physician over 5 years
– $30,000 of $44,000 is available during the first 2 years (2011,
2012)
• 2% reimbursement of Medicare revenues available from
CMS for PQRI reporting
• 2% reimbursement available from Medicare available for
e-prescribing
– Reimbursement begins to decrease in 2011

18.
What is Interoperability in Healthcare?
• The ability for EMRs to electronically share data and
communicate with one another
• The systemic exchange of patient health information
• The exchange of patient health information between
entities, providers, patients, health plans,
pharmaceuticals and laboratories
• Regional health information organizations as a means of
centralizing patient data exchange for communities

23.
Return on Investment (ROI) of an EMR
Revenue Opportunities with an EMR
• Improved accuracy of documentation most of the time
leads to better coding, more revenue
• Increase in charge capture of services and improvement
accuracy of claims
• Negotiate quality performance outcomes within payer
contracts
• Reduce redundancy of diagnostic testing
• Financial Incentives for early adopters

27.
Implementation Concepts as You Build Your
Work plan
• Incorporate the 80-20 Rule in your system design
– Avoid designing a solution for 20% of the cases
– Focus on the 20% of cases that represent 80% of your solution
• Create your project team based on expertise and
communication
• Project management is critical to your success
• Engage your physicians and key influencers
• Prepare to test and train
• Develop your implementation infrastructure

28.
Physician Involvement
• Common mistakes to avoid
– Overestimating physician confidence with electronic solutions
– Under involvement of physicians in the EMR selection and the
consensus building process
– Limiting the physician involvement in the design and
implementation phases
• Design the electronic process around the exam room
encounter
• Templates and tasks need to support the physician’s
specialty and not a generic electronic note

29.
Consider Changes From The Paperwork
Workflow Process
• The paper chart versus electronic templates
– How is the chart set-up and organized for different patient visits?
• Incoming lab and ancillary results
– Need to consider how they are incorporated into the electronic
record versus review and sign-off
• Process to notify patients of results
• Leverage electronic technology with faxes, scanning and
e-mail
– Consideration to HIPAA and patient confidentiality

30.
Document Conversion
• Need to create a plan for
conversion of records and incoming
information
• Are their archived transcription
files?
• Consider how far back in time to
begin the patient record conversion
– 3 year history
– Appointments for the next 6 months
• Scanning of current and new
patients
– How much of the chart and how far
back?

31.
Consider New Ways to Manage the
Revenue Cycle
• Evaluate how you managed your Revenue Cycle before
an EMR implementation
– Was/Is it effective?
• Were you effectively using your Practice Management
System and/or Business Intelligence tools to manage?
• What tools does your EMR offer to manage the functions
you implemented?

33.
Background
• 10 provider group practice with 3 clinic locations
• Large amount of managed care contracts and 30%
governmental payers
• Few reports were used to manage revenue cycle
functions
• Practice management system was underutilized
• The revenue cycle activities required automation and
efficiencies in order to maximize outcomes

34.
Implementation Strategy
• Selected a powerful and well respected EMR Vendor
• Phased approach to design and implementation
• Implementation lacked physician input
– Many of the staff had little working knowledge of EMR
– Most staff tasked with designing EMR had little knowledge of
clinical or revenue cycle operations
• Most physicians were reluctant to adopt EMR, despite a
directive from leadership that adoption was mandatory

35.
Outcomes at Go-live
• Lack of workflow redesign led to many operational
inefficiencies
• Rather than scan at the clinic sites, all documents were
batched and sent to the Business Office, leading to
misplaced documents that were often scanned to the
wrong chart
• Physicians reluctance and a directive from management
to adopt, led to the design committee pacifying
physicians rather than implementing the solution to its
fullest

36.
Outcomes at Go-live (Con’t)
• Many of the template and edit features of the EMR were
disabled for fear of “disrupting the physician’s ability to
see patients”
• Features designed to facilitate coding and correct charge
capture on the front end were under utilized creating a
bottle neck of errors in the business office
– ROI on staffing in the clinics were countered with an increased
need for staff in the business office to manage charge capture
process

37.
EMR Intervention
• Refocused the design team to include a physician
champion with a strong clinical support person
• Created detail clinical process flows to identify areas of
efficiency and automation
• Implemented e-prescribing with all providers
• Created templates around the physicians practice style
allowing for coding and documentation efficiencies

38.
Current State
• Physicians began to realize efficiencies with EHR
technology
• Completed a process redesign of the entire revenue
cycle
• Automated many of the manual processes that remained
after the go-live
• All Clinical documents are now scanned at the office site
• Physicians went through a reeducation process of
clinical workflow and EMR benefits to change attitudes
and behaviors
• After 3 months, the EMR begin to contribute to improve
revenue for the practice

39.
Where do you go from here?
• Talk with colleagues and APP to assist with decision
making
• Give serious consideration to the hospital preferred
vendor solution
• Your decision will come based more about “when” to
implement and not “if”
• Begin thinking about your practice’s strategic goals and
implementation objectives
• Network, network, network
• When it finally comes down to moving forward, it’s really
not about the technology, it’s about the clinical
processes and workflows